When Burden Becomes Rationing: Design Architecture and Procedural Attrition in Medicaid Work Requirements

Abstract This article examines how the design architecture of Medicaid work requirements shapes procedural attrition across the enrollment lifecycle. Using publicly available data from Arkansas and Georgia, the only two states to have operationalized work requirements prior to the federal mandate in H.R. 1 (P.L. 119–21), the analysis compares attrition patterns across two structurally distinct designs. Arkansas imposed requirements as a maintenance condition on enrolled populations, concentrating attrition at reporting checkpoints. Georgia imposed them as both an entry and maintenance condition, with attrition concentrated at the pre-application stage. The article extends Herd and Moynihan’s administrative burden framework. It proposes that when administrative burden becomes the dominant determinant of program participation, burden shifts from implementation friction to a rationing mechanism that allocates coverage based on administrative capacity rather than statutory criteria. The article evaluates three observable implications of this framework. Specifically, reporting frequency shapes procedural disenrollment, point of imposition determines where attrition concentrates, and targeted burden reduction produces only partial enrollment gains when exclusion is embedded across multiple design features. Comparative evidence supports H2 and is consistent with H1. Georgia’s 2025 burden-reduction reforms provide preliminary directional evidence relevant to H3, with confirmatory testing requiring post-reform data not yet available. The findings carry direct implications for the 41 expansion states required to implement work requirements by January 2027, where variation in administrative design will systematically shape coverage outcomes.